Sexual surrogacy is an often overlooked and misunderstood concept
in modern society where it is frequently seen as being a type of glorified
prostitution. In fact, sexual surrogacy functions as a real and meaningful
form of erotic communication and self-realization and is practised widely
in the United States. People with disabilities in the Canadian province
of Ontario who may not have access to sexual partners and who are seeking
greater personal fulfillment should have the cost of sexual surrogates
incorporated into their government-sponsored personalized funding program
in order to access this critical aspect of disability rehabilitation
whose fundamental objective is the achievement of sexual self-esteem.

The struggle for social equality for people with disabilities is relatively
new. While other minority groups such as People of Colour, Jews, Muslims
and Gays and Lesbians have all succeeded to a significant degree in securing
legislation in Ontario (most notably through the Ontario Human Rights
Code) which protects and defends their inalienable right to be equal citizens
of the province, people with disabilities continue to struggle with culturally
sanctioned ableism which challenges their right to be equal citizens of
society, entitled to the same expectation of dignity by others.

Despite the hopeful promise of the proposed Ontarians With Disabilities
Act legislation, Ontarians with disabilities themselves are still actively
involved in vindicating their rights not merely as a segment of the chronic
care population, but as a legitimate and recognized cultural minority
within Ontario whose rights to a secure, happy and hopeful future should
be within their reach as easily as it may be for other minority groups
in the province. Inherent to the international disability rights movement
is the objective of people with disabilities to be seen as other members
of society who share similar social needs and expectations and who are
recognized as complex human beings entitled to the same rights and social
functioning as other minority groups. Fundamental to such social complexity,
is the reality of human sexuality and the right of every human being to
be recognized as a sexual being and to be able to express their sexuality
in the context of their sexual orientation in appropriate ways in an attempt
not only to enjoy sexual gratification, but also to manifest their identity
as a sexual being and to claim their right as an equal member of society
regardless of their age, gender, race, religion, sexual orientation or
ability.

For many Ontarians with Disabilities, opportunities to locate partners
and express their sexuality are limited. Though people with disabilities
are more independent and integrated in society than they ever were before,
many still feel the misperception of people with disabilities as being
asexual and poorly socialized. Medical practitioners rarely discuss sexual
issues with their patients who have a disability. Often rehabilitation
specialists avoid issues of sexuality for fear of embarrassing their client.

While concerns about sex and sexuality are raised in certain contexts,
the opportunity to be sexual and reclaim their bodies is often not a possibility
for many Persons With Disabilities. This is particularly unfortunate for
people with disabilities who may have been single prior to acquiring their
disability and perhaps were not sexual at an earlier time in their life.
Sexuality is a complex and highly misunderstood concept in our society
where so many people equate sexuality with intercourse itself and cannot
appreciate the important learning experience of being sexual and how being
sexual transcends sexual behavior per se and often can be part of an enormously
larger healing process.

It is the intent of this position paper to espouse the idea of sexual
services for people with disabilities in Ontario by examining the role
of sexual surrogates as a therapeutic mechanism in the on-going rehabilitation
of Persons With Disabilities and to suggest the Ontario Ministry of Health
incorporate sexual surrogacy into its Direct Funding Program and thus
allow Centres for Independent Living to assist people with disabilities
in Ontario to access sexual surrogates as a type of assistive care in
conjunction with the government-sanctioned attendant care they may be
already be receiving.

Starting as a pilot project in 1994 and becoming a permanent program
in 1998, The Direct Funding Program which is funded by the Ontario Ministry
of Health and administered through the Centre for Independent Living in
Toronto, follows the philosophy of the Independent Living Movement which
espouses the idea that persons with disabilities should have the right
to control their own lives and not be ghettoized or made invisible by
society. In order to maximize disability independence, The Direct Funding
Program allows people with physical disabilities to manage their own attendant
care through a pre-arranged agreement between themselves and their attendant
care worker(s).

In the context of the Direct Funding Program, attendant care refers to
individuals who assist the person with a disability in the physical assistance
of performing everyday duties they would normally be able to perform if
not for their disability. Such assistance would likely include transferring,
showering, dressing and undressing. The Direct Funding Program allows
the person with a disability to hire or fire the attendant worker who
is brought to the attention of the person with a disability through their
independent living center which provides funding to the individual. The
person with a disability thus becomes an equal partner in the attendant
care as it is they who assume responsibility for the arrangement and the
management of the payment to the attendant worker. The Direct Funding
program is therefore a "self-management" program for the person
with a disability allowing them greater control over the quality of their
care and at the same time requiring them to be responsible in the disbursement
of funding and additional administrative responsibilities.

The Direct Funding program is restricted to those 16 years of age or
over who are residents of the province of Ontario and require attendant
care due to a permanent physical disability. It requires the individual
to meet with a selection panel to discuss their needs and to ensure the
individual is responsible and can meet the on-going requirements of the
program. The Direct Funding Program is restricted to an understood set
of requirements and duties of the attendant. At this time the attendant
is not responsible for providing sexual services to the people they help
nor are they required or expected to engage in any kind of therapeutic
intervention as would be provided by, for example, a physiotherapist.

Attendants are not required to discuss sexual issues with their employers.
("Employers" in this discussion refers to the person with a
disability who hires the attendant. It is the principle of the Direct
Funding Program that the person with a disability is in fact employing
the attendant with funds provided). Attendants are not expected to provide
sexual gratification nor are they necessarily expected to purchase pornographic
or adult material for their employers. The average number of hours per
day the attendant will serve is normally six which in the context of the
other duties they are required to perform would make it difficult to incorporate
sexual services in their list of duties. Neither The Abilities Foundation
nor the Canadian Association of Independent Living Centres has any policy
on the use and/or benefit of sexual surrogacy for people with disabilities.
At the present time, Canadian law remains ambiguous on this issue while
at the same time certain American states have legalized sexual surrogacy
recognizing it as a therapeutic benefit to the patient.

There currently exists no broad-based disability rights organization
in Canada that has made any public statements concerning the sexual rights
of Canadians with disabilities. It would be most unfortunate if, based
on such social irresponsibility, the public assumed that people with disabilities
do not seek therapeutic sexual services simply because their presumed
spokespeople do not engage the media in this most relevant and worthwhile
aspect of disability rehabilitation.

In summary, there does not exist at the present time any type of organized
sexual services offered to people with disabilities within the province
of Ontario. Nor does there exist any effort by disability rights organizations
on a national or provincial level to secure the sexual rights of people
with disabilities within a health care framework. It would appear an organized
effort on this issue is lacking, but such a judgement would neglect the
reality which is that thousands of people with disabilities living in
Ontario are sexual beings and thus have the right to manifest that identity
in ways they see fit. The reality is that persons with disabilities seek
sexual gratification, body awareness, greater personal bonding with others
and the opportunity to understand their bodies on both a physical and
erotic level. Present health care policy in Ontario does not recognize
this and therefore this very real need must be addressed.

New Thinking and Approaches - What Sexual Surrogacy Is
and What It Is Not

In order to meaningfully understand the dynamics of sexual surrogacy
and its lasting social implications it is imperative to have a clear comprehension
about the issue before us. Simply put, sexual surrogacy is not prostitution
nor is it simply gratification in its most vulgar meaning. Sexual surrogacy
is a therapeutic process which attempts to have the patient begin a dialogue
with their own body in an attempt to, in a meaningful way, transcend simple
gratification.

Research in this area has found a remarkable disparity between what sexual
surrogates actually do and how the public perceives them. The most common
activity performed by a surrogate was not sexual intercourse, but actually
simple touching. The second most common activity recorded was not sexual
intercourse either, but rather simply talking to the patient and giving
reassurance and support. While sexual intercourse and oral sex exist as
part of a sexual surrogate's repertoire, it does not represent the essence
of the surrogate. In the context of disability we are not focused exclusively
on gratification either. It is the concept of sexual self-esteem that
is at the heart of this type of therapy.

What do we mean by sexual self-esteem? Clinically speaking, sexual self-esteem
refers to "a positive regard for and confidence in an individual's
capacity to experience his/her sexuality in a satisfying and enjoyable
way." Sexual self-esteem therefore relates to how we see ourselves
as facilitators of our own sexual gratification, but at the same time
it must imply the ability to accept one's own body as both attractive,
whole and sexually relevant. Clearly the impact of disability on sexual
functioning can have a significant effect on a person's sexual self-esteem.

In spinal cord related injuries, the ability to maintain an erection,
experience orgasm or even to have children can impact the sexual self-esteem
of the disabled person. Common concerns like "Will I still be able
to have sex?" "Who would want to have sex with me?" and
"Will I be able to satisfy my partner?" are all frequent questions
heard by sex therapists who work with people with disabilities. What is
important is to recognize that sexual self-esteem is a critical aspect
to the patient's lifetime of rehabilitation both physically and emotionally.
When we feel good about ourselves we simply do better whether it is professionally
or personally. When we feel good about our bodies, when we can recognize
and appreciate our own sexuality beyond the perceived impairment the disability
may have caused, when we can see that sexuality exists beyond intercourse
and immediate gratification, then we develop a healthy sexual self-esteem
and then are able to place disability into a compartment which does not
overwhelm our lives. This is not to minimize the significant challenges
people with disabilities face, but it is the foundation of disability
theory that it is society's perception of people with disabilities that
can often be their greatest impediment. Often such attitudes include the
myth that people with disabilities are asexual or that they are all heterosexual.
Such attitudes limit the social development of people with disabilities.

Then what exactly are the type of services a sexual surrogate would provide
to a person with a disability? Interviews conducted with sex workers in
Toronto for the purpose of this research have illuminated a number of
activities which are consistent with the research which lists intercourse
as having a minimal presence in the type of sexual services normally provided
to the patient.

A female bisexual sex worker who works with lesbian women, gay men and
heterosexual couples begins her services by simply talking to the patient,
getting to know them, understanding their anxieties, setting boundaries
about the therapy and most importantly creating a sense of trust in the
relationship to ensure maximum therapeutic value in the services provided.
Breathing exercises are often incorporated as well. Physical interaction
with the patient normally begins with what has been referred to as "sexually
related therapeutic touch" in which the surrogate gently massages
the patient with massage oil and engages in gentle strokes all over the
patient's body while soothing music is played.
Within the therapeutic encounter, more explicit sexual practices have
a meaningful and useful role to play in the session. Usually after fifteen
minutes once the session has begun, the surrogate may focus on the client's
desire to achieve multiple orgasm or to delay orgasm in order to reach
a greater level of climax through back stimulation in conjunction with
explicit genital play through the use of the surrogate's hands. Avoiding
intercourse by focusing on genital play in the context of the client's
expressed desire for orgasm and/or multiple orgasm, this technique has
often resulted in gratification by the client and is a useful way in achieving
both orgasm and sexual self-esteem. There is often no agenda around genital
stimulation within sexual surrogacy.

Another highly effective technique is simply talking to the client about
what works for them. This technique may be attempted at the beginning
of the session and while may seem innocuous, can often lead to significant
arousal by simply letting the client verbalize their desires to their
surrogate. Fundamentally speaking, the greatest single physical interaction
attempted by the surrogate is the experience of receiving touch as it
is manifested at different points in the session. Recalling that the client
had rarely received touch since acquiring their disability, the experience
of receiving touch becomes highly eroticized in this context. In both
the pursuit of arousal and multiple orgasm, these sexual techniques become
highly valuable to the surrogate at key moments in the session

The goal throughout is not exclusively to achieve orgasm in the patient
nor is it to provide genital stimulation per se. The ultimate benefit
of this type of therapy is to increase the sexual self-esteem of the disabled
person through the physical pleasure of non-penetrative bodily contact
and to help the disabled person learn about their own body. Often patients
are so overwhelmed by this kind of intimacy that they had rarely experienced
since their injury, that they are often brought to tears and a greater
sense of letting go about themselves. The release of erotic energy and
the opportunity to experience their sexuality became a huge therapeutic
benefit to the patient. They have transcended societal perceptions of
disabled people as being asexual and they have recognized their own innate
sexuality and sexual self-esteem.

Recommendations

It is therefore recommended that sexual surrogacy be incorporated into
the Ontario Direct Funding Program whereby a list of sexual surrogates
will be made available to Independent Living Centres and that clients
seeking sexual services will be able to access sexual surrogates through
these centers and pay surrogates out of the funding currently provided
to them through the Direct Funding Program. Most sessions with sexual
surrogates may be between forty five minutes to an hour and half. Rates
can be expected to be between one hundred and one hundred and fifty dollars.
Because of the public misperceptions regarding sexual surrogacy, it is
recommended that a sexual surrogacy pilot project be offered on a small
scale dealing only with lesbian women with disabilities who seek a female
sexual surrogate. Sex workers interviewed for this research have strong
connections to the feminist community and recognize the sexual diversity
of the disability community.

In an effort to anticipate misperceptions of this type of work by a larger
repressed health care authority structure, the use of female sexual surrogates
to provide women with disabilities same-sex therapy is an effective and
discreet way to begin to analyze the long term benefits of this type of
service free of the oppressive and disability-ignorant health care system.
Lesbian women are a minority certainly within the spinal cord injured
community and deserve recognition of their place within the disability
community and of their status as a sexual minority. Sexual surrogacy among
lesbians would be more readily accepted than among heterosexual or gay
male communities because the lesbian community itself has a lesser media
visibility than these groups and has historically operated in a much more
discreet and less overtly sexualized way.

In addition, it is the position of this author that since women with
disabilities have been consistently undertreated by the rehabilitation
industry which has traditionally placed disability in a male context,
women with disabilities deserve every opportunity to access new social
policy which is geared toward their empowerment. Lesbian organizations
have historically gravitated toward the women's movement which has placed
sexuality on a continuum of unjustified gender bias whereas the male gay
community has often manifested itself through its overt and highly visible
desire to secure sexual gratification. In any major urban area in North
America, gay male bath houses consistently outnumber any such similar
establishments for women if indeed such establishments for women exist
at all. Such reality creates and reinforces a public perception that gay
men are more sexually driven than lesbians though no literature currently
exists to support that.

By capitalizing on this public misperception of overt homosexual conduct
distinguished by gender, a test pilot sexual surrogacy project focusing
on lesbians veers away from the misperception of this work as prostitution
and in offering this social progress recognizes the historic mistreatment
women with disabilities have received by the health care industry.

Summary

It is recommended that a sexual surrogacy test pilot project operating
out of the Ontario Direct Funding Program be attempted for lesbian women
with disabilities for the following reasons:

i) Sexuality is an inherent aspect of being human and the opportunity
to express that sexuality is a right of all people.

ii) Done under controlled conditions in a therapeutic setting by a professional,
sexual surrogacy can have a tremendous positive impact in developing the
sexual self-esteem of the person with a disability and broadening their
perception of themselves beyond their disability.

iii) Women with disabilities are equal members of both the disabled community,
the gay/lesbian community and the women's movement and thus deserve equal
consideration regarding their needs to be sexual with other women.

There are many social and legal implications for this type of service
to be funded by a provincial government. Admittedly, Canadian law is ambiguous
on the issue of sexual surrogacy. However, it is the position of this
author that state-sanctioned sexual conduct is found in many public places
in Canadian society not the least of which can be found in the male homosexual
community where it is common knowledge that gay men gather to have sex
with each other in so called "bath houses". Such conduct would
not be tolerated in a heterosexual context. Clearly, society has afforded
a special consideration to the male gay community regarding their sexual
conduct in the belief that gay men have been historically persecuted for
their sexuality and thus denied opportunity to assemble in an organized
way to celebrate that sexuality.

If such consideration is offered to gay men, such consideration should
be offered to people with disabilities who too have been persecuted, stigmatized
and ghettoized into systemic social invisibility and in the process have
been denied their inalienable right to be sexual. Therefore, it is the
position of this report that legal exemptions be offered to the Canadian
Association of Independent Living Centres in their service of providing
sexual surrogates to people with disabilities as this type of work has
an undeniable therapeutic value. The sexual rights of people with disabilities
should not suffer the same ignorance that the dominant able-bodied community
has dictated to them regarding other aspects of their lives.

The financial implications of including sexual surrogacy into the Direct
Funding Program are real, but not overwhelming. In the context of a test
pilot program, initial funding for a six month period for perhaps fewer
than a dozen women receiving sexual services possibly once or twice per
month could represent costs of approximately twenty five thousand dollars
to begin with.

The same restrictions would apply to the sexual services as they would
apply to other requirements of the Direct Funding Program, i.e., the individual
must be at least 16 years of age, must have a physical disability, be
responsible for additional administrative requirements and also be able
to evaluate the quality of such services. A list of sexual surrogates
would be available at the Centre For Independent Living. Surrogates would
then provide services in the privacy of the homes of their employers.
A list of sexual surrogates can be created through the Toronto Sex Worker's
Network and through tantric massage therapists in the area as well as
through local contacts such as the sex worker identified in this study.

The idea of sexual surrogacy may seem daring, but it is not new. In the
United States sexual surrogates work in a variety of settings and, depending
on the state they are working in, their professional conduct is legal
and well appreciated. The International Professional Surrogate Association
in California has had much experience in working with people with disabilities
and has had much success.

Sexual surrogacy is a legitimate and relevant professional service. Clearly
it is time such services became available to people with disabilities
in Canada as the therapeutic value of such services has been clearly identified
through scholarly research. The Ontario Ministry of Health now has the
opportunity to recognize the sexuality of people with disabilities by
extending funding of the Direct Funding Program to include sexual surrogacy
which as we have seen is actually not sexual in nature, but pertains more
to identifying and developing the sexual self-esteem of disabled people
thereby providing a real and meaningful therapeutic value to them.

A test pilot project directed exclusively to lesbian women with disabilities
would divert the public's perception of this type of work as prostitution
by removing it from a heterosexual context and placing it in a feminist
context geared toward the sexual empowerment of disabled lesbians. It
is the position of this report that after a trial six month period, employers
will have greatly enjoyed and appreciated the service provided by these
surrogates and would want this additional funding to be shared by other
people with disabilities in the province.

I would like to close this position paper through the words of a man
with cerebral palsy who had worked with a sexual surrogate and had conveyed
his sense of happiness about the experience to his mother who commented
that her son felt good about himself, that he wanted to do it again, that
he felt a sense of wholeness. For her son, sexual surrogacy had become
an integral and essential aspect of both his rehabilitation and his own
self-respect as a person with a disability.